Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0474, written 27 Nov 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 Nov 2023 |
|---|---|
| Reference | 2023-0474 |
| Deceased | Mohammed Akram |
| Coroner | Melanie Lee |
| Coroner area | Inner North London |
| Category | Suicide (from 2015) |
| Organisation named | Barnet, Enfield and Haringey Mental Health NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Mohammed Zeeshan Akram (Zee) (died 21 March 2023)
THIS REPORT IS BEING SENT TO:
1. Barnet Enfield and Haringey Mental Health NHS Trust
1
CORONER
I am: Melanie Sarah Lee
Assistant Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and The Coroners (Investigations)
Regulations 2013, regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 27 March 2023 an investigation was commenced into the death of
Mohammed Zeeshan Akram, date of birth 22 November 1993. The
investigation concluded at the end of the inquest on 6 September 2023.
The conclusion was suicide. The medical cause of death was 1a.
multiorgan failure; 1b. acute ethylene glycol toxicity; 2. mental health
disorder.
4
CIRCUMSTANCES OF THE DEATH
Zee had a history of suicidal ideation and reported suicide attempts
dating back to his childhood. In February 2019 he was diagnosed with
a psychotic disorder. He received support for his mental health from the
Crisis Team in 2019 and spent two days as a mental health inpatient.
In December 2022 Zee reported panic attacks and auditory
hallucinations. He was taken on by the Crisis Team who prescribed
diazepam, zopiclone, olanzapine and fluoxetine. On 30 December
there was a joint review by the Home Treatment Team and Haringey
(BEH) Early Intervention Service (EIS) at St Ann’s Hospital and Zee
was allocated a care coordinator. On 30 December Zee was
1
discharged from the Home Treatment Team who wrote asking the GP
to continue repeating his medications which were zopiclone
olanzapine
and diazepam
, fluoxetine
.
In February 2023 Zee’s mental health deteriorated. On 15 February he
reported EIS that he was experiencing negative side effects from his
medication but that he felt mostly optimistic. He requested a reduction
of olanzapine.
There was an exchange of text messages between Zee and a dual
diagnosis recovery worker between 17 February and 15 March in which
Zee appeared upbeat, said that he was attending work and gave no
cause for the recovery worker to be concerned.
On 16 March Zee attended an appointment and informed his recovery
worker that he had stopped taking his olanzapine and fluoxetine 2
weeks previously due to numbness that had led to suicidal ideation.
The recovery worker went out of his way to arrange an urgent medical
review for Monday 20 March. Zee was given safety netting advice.
After this appointment, Zee went to
several hours contemplating throwing himself into the Thames. He did
not inform his recovery worker of this or contact the crisis team.
where he spent
On Friday 17 March the recovery worker sent Zee a text message with
the appointment for a medical review on Monday 20 March. Zee replied
that he was unable to make the appointment as he was working on the
Monday and so the appointment was rearranged for Tuesday 21
March.
On 20 March Zee did not attend work. A friend went to his flat and
found Zee unresponsive. Zee was taken to the Whittington Hospital
where he died on 21 March 2023.
5
CORONER’S CONCERNS
During the course of the inquest, the evidence revealed matters giving
rise to concern. In my opinion, there is a risk that future deaths will occur
unless action is taken. In the circumstances, it is my statutory duty to
report to you.
The MATTERS OF CONCERN are as follows.
I heard evidence that there was no routine mechanism to cross reference
what people are prescribed and what medication they are actually
collecting, and no automatic notification to GPs who are responsible for
the medication prescribing. Zee informed BEH that he had not taken his
olanzapine and fluoxetine for two weeks. His GP, who was prescribing
that medication, was not informed.
2
I am concerned that GPs are not updated, particularly where patients
have expressed suicidal ideation, and may not be aware that people are
not taking medication and/or that there may be a risk of stockpiling.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that your organisation has the power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 22 January 2024. I, the coroner, may extend
the period.
Your response must contain details of action taken or proposed to be
taken, setting out the timetable for action. Otherwise you must explain
why no action is proposed.
8
COPIES and PUBLICATION
I have sent a copy of my report to the following:
•
•
•
• HHJ Thomas Teague QC, the Chief Coroner of England & Wales
(Zee’s brother)
(Zee’s friend)
(Zee’s GP)
I am also under a duty to send a copy of your response to the Chief
Coroner and all interested persons who in my opinion should receive it.
I may also send a copy of your response to any other person who I
believe may find it useful or of interest.
The Chief Coroner may publish either or both in a complete or redacted
or summary form. He may send a copy of this report to any person who
he believes may find it useful or of interest. You may make
representations to me, the coroner, at the time of your response, about
the release or the publication of your response.
DATE SIGNED BY ASSISTANT CORONER
27 November 2023
9
3
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Private & Confidential
For the attention of:
His Majesty’s Assistant Coroner Inner
North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
Senior Service Lead
Haringey Community Mental Health Services
Barnet, Enfield and Haringey Mental Health NHS Trust
St. Ann’s Hospital
St. Ann’s Road
Tottenham
London
N15 3TH
18th January 2024
Dear Madam,
Regarding: Mr Mohammed Zeeshan Akram (Zee)
DOB: 22/11/90
Date of death: 21/03/2023
Address: Known to the Trust
This letter forms the Barnet Enfield and Haringey Mental Health NHS Trust’s (“the Trust”)
response to the application sections of the Prevention of Future Deaths Report following the
hearing regarding the death of Mr Mohammed Zeeshan Akram (Zee), held on 6th September 2023
before Assistant Coroner Lee at St Pancras Coroner’s Court.
The MATTERS OF CONCERN are as follows.
I heard evidence that there was no routine mechanism to cross reference what
people are prescribed and what medication they are actually collecting, and no
automatic notification to GPs who are responsible for the medication prescribing.
Zee informed BEH that he had not taken his olanzapine and fluoxetine for two
weeks. His GP, who was prescribing that medication, was not informed.
I am concerned that GPs are not updated, particularly where patients have
expressed suicidal ideation, and may not be aware that people are not taking
medication and/or that there may be a risk of stockpiling.
The above matters were considered, and the following response is provided.
The usual procedure within the Early Intervention Psychosis Service (“the service”) when the clinical
team become aware that a client is not taking their medication as prescribed, is to discuss this with
the client, their family, and carers (where appropriate) to understand the reasons behind this and to
support the client to continue with the medication as prescribed wherever possible.
In situations where the client is experiencing side-effects, has stopped their medication completely
or is requesting a change in medication, a review with the prescribing clinician will be arranged. The
timeframe for this review will be informed by the urgency of the issue and associated risks. In the
service, one in three of the medical appointments are always available for urgent reviews within five
working days.
This medication review by the prescribing clinician will automatically lead to the GP being notified
when there are any changes to the client’s prescription or treatment plan, including whether the
client has stopped taking the medication and any steps the service is taking to provide additional
support. The expected standard is the GP would receive this correspondence via email within 48
hours of the medical review. In cases where a rapid medical review is arranged, the service will
usually wait until the review before updating the GP, to ensure the GP is provided with the most up
to date treatment plan.
Where there are concerns about a use of specific medication, e.g., benzodiapenes or Lithium,
clinicians will routinely liaise with GPs to ensure safe prescribing, outside of planned medical
reviews.
In this case, the clinician became aware the client had stopped taking his prescribed medication on
Thursday 16th March 2023, which led to a multidisciplinary team (MDT) discussion at which the
agreed plan was for an urgent medical review. This was arranged for Monday 20th March 2023,the
next available urgent appointment. The MDT discussion also considered whether a referral to a
Crisis Resolution & Home Treatment Team was warranted, but felt the threshold was not met.
Since the medical review was arranged for two working days after the service was made aware the
client had stopped their medication, we would not have expected additional communication with the
GP prior to the medical review.
The Trust is grateful for the opportunity to review procedures following Mr Akram’s passing.
Finally, the Trust offers its sincere condolences to the family and friends of Mr Akram. In doing so,
the Trust remains committed to the delivery of patient-centred care to its service users.
We hope the above has addressed the matters raised in the Prevention of Future Deaths report.
Yours sincerely,
Senior Service Lead
Haringey Community Mental Health Services
Barnet, Enfield and Haringey Mental Health NHS Trust
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